{"id":201,"date":"2018-09-14T11:05:32","date_gmt":"2018-09-14T10:05:32","guid":{"rendered":"https:\/\/mes-formulaires.cpamcentre.fr\/?page_id=201"},"modified":"2018-09-18T09:07:08","modified_gmt":"2018-09-18T08:07:08","slug":"demande-pfidass","status":"publish","type":"page","link":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/demande-pfidass\/","title":{"rendered":"Demande d&rsquo;accompagnement pour l&rsquo;acc\u00e8s aux soins"},"content":{"rendered":"<p>Vous \u00eates confront\u00e9 \u00e0 une personne en situation de renoncement aux soins ? Orientez-la vers le dispositif d&rsquo;accompagnement personnalis\u00e9 propos\u00e9 par l&rsquo;Assurance Maladie en compl\u00e9tant le formulaire ci-dessous.<\/p>\n<p><strong>Attention, seuls les assur\u00e9s du r\u00e9gime g\u00e9n\u00e9ral peuvent b\u00e9n\u00e9ficier de cet accompagnement.<\/strong><\/p>\n<hr \/>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f202-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"202\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/201#wpcf7-f202-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulaire de contact\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"202\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f202-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div id=\"formulaire-responsive\" class=\"clearfix\">\n\t<div class=\"rang-form\">\n\t\t<div class=\"colonne\">\n\t\t\t<h4 style=\"padding-top:0;margin-top:0;\">1. Coordonn\u00e9es du partenaire-d\u00e9tecteur\n\t\t\t<\/h4>\n\t\t\t<p>&nbsp;<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Consentement\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"Consentement[]\" value=\"Le d\u00e9tecteur certifie avoir recueilli le consentement de l&#039;int\u00e9ress\u00e9 pour \u00eatre contact\u00e9 et accompagn\u00e9 par les Conseillers Assurance Maladie.\" \/><span class=\"wpcf7-list-item-label\">Le d\u00e9tecteur certifie avoir recueilli le consentement de l&#039;int\u00e9ress\u00e9 pour \u00eatre contact\u00e9 et accompagn\u00e9 par les Conseillers Assurance Maladie.<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"rang-form\">\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Nom*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Nom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Nom\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Pr\u00e9nom*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Prenom\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Prenom\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"rang-form\">\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Structure<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Structure\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Structure\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Fonction*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Fonction\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Fonction\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"rang-form\">\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Email*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"Email\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>T\u00e9l\u00e9phone*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Telephone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"Telephone\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"rang-form\">\n\t\t<div class=\"colonne\">\n\t\t\t<p>&nbsp;\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"colonne\">\n\t\t\t<h4 style=\"padding-top:0;margin-top:0;\">2. Coordonn\u00e9es de l'assur\u00e9 \u00e0 recontacter\n\t\t\t<\/h4>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"rang-form\">\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Nom\/Pr\u00e9nom*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"NomPrenomAss\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"NomPrenomAss\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Date de naissance*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DateNaissance\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"jj\/mm\/aaaa\" value=\"\" type=\"text\" name=\"DateNaissance\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"rang-form\">\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>T\u00e9l\u00e9phone*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"TelephoneAss\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"TelephoneAss\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"demi-colonne\">\n\t\t\t<p>Email<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"EmailAss\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"EmailAss\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"rang-form\">\n\t\t<div class=\"colonne\">\n\t\t\t<p>&nbsp;\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"colonne\">\n\t\t\t<h4 style=\"padding-top:0;margin-top:0;\">3. Pr\u00e9cisions compl\u00e9mentaires\n\t\t\t<\/h4>\n\t\t<\/div>\n\t\t<div class=\"colonne\">\n\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Precisions\"><textarea cols=\"110\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"Precisions\"><\/textarea><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<table>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><b>Merci de saisir le code affich\u00e9 ci-dessous pour valider votre envoi : <\/b><br \/>\n<input type=\"hidden\" name=\"_wpcf7_captcha_challenge_captcha-170\" value=\"836469528\" \/><img decoding=\"async\" class=\"wpcf7-form-control wpcf7-captchac wpcf7-captcha-captcha-170\" width=\"72\" height=\"24\" alt=\"captcha\" src=\"https:\/\/mes-formulaires.cpamcentre.fr\/wp-content\/uploads\/wpcf7_captcha\/836469528.png\" \/><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"captcha-170\"><input size=\"4\" maxlength=\"4\" class=\"wpcf7-form-control wpcf7-captchar\" autocomplete=\"off\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"captcha-170\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/table>\n\t<div class=\"rang-form\">\n\t\t<div class=\"colonne\">\n\t\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Envoyer\" \/>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n<\/div><!--fin de formulaire-responsive--><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"25\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>Vous \u00eates confront\u00e9 \u00e0 une personne en situation de renoncement aux soins ? Orientez-la vers le dispositif d&rsquo;accompagnement personnalis\u00e9 propos\u00e9 par l&rsquo;Assurance Maladie en compl\u00e9tant le formulaire ci-dessous. Attention, seuls les assur\u00e9s du r\u00e9gime g\u00e9n\u00e9ral peuvent b\u00e9n\u00e9ficier de cet accompagnement.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-201","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/201"}],"collection":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/comments?post=201"}],"version-history":[{"count":4,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/201\/revisions"}],"predecessor-version":[{"id":315,"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/pages\/201\/revisions\/315"}],"wp:attachment":[{"href":"https:\/\/mes-formulaires.cpamcentre.fr\/index.php\/wp-json\/wp\/v2\/media?parent=201"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}